Advance Care Planning

1. Advance Care Planning Katja Elbert-Avila, MD Mitchell Heflin, MD, MHS Anthony Galanos, MA, MD

2. Goals • Overview: • Define Advance Care Planning and Advance Directives • Identify potential barriers to and limitations of advance directives • Describe components of a discussion on advance care planning

3. Goals • Discussion: • Given a case, demonstrate an advance care planning discussion

4. Advance Care Planning • Process to help people formulate preferences for future medical care in the event of decisional incapacity • Autonomy and the right to self-determination • Requires individuals to assess values and preferences, and act to realize these values -Emanuel, EJ, Emmanuel LL. Four models of physician-patient relationship. J Am Med Assoc 1992: 267(16): 2221-2226

5. Advance Directives • Mechanism for communicating and/or documenting Advance Care planning • “Document in which you give instructions about your health care if, in the future, you cannot speak for yourself” -AMA website. 1995; AARP, ABA commission on legal problems of the elderly, and AMA

6. Types of Advance DirectivesProxy Directives • Durable power of attorney for health care (surrogate decision maker) • “Legal mechanism to transfer authority to make medical decisions to a specified person in the event of decisional incapacity” - Fischer, GS et al. Clinics in Geriatric Medicine. 2000;16: 239-254

7. Types of Advance DirectivesInstructional Directives • Living Wills • “Give instructions about what specific treatments should be given or withheld under certain clinical circumstances” if pt incompetent • Fischer, GS et al. Clinics in Geriatric Medicine. 2000;16: 239-254 • Most states have laws that provide special forms and signing procedures • Typically 2 witnesses and a notarized signature

8. Types of Advance Directives Instructional Directives • Living Wills • May be limited in terms of situations in which they apply • May not describe in detail interventions to be given or withheld • Operative if pt becomes incompetent

9. Types of Advance DirectivesInstructional Directives • Orders to limit treatment • Extensions of instructional directives • i.e. DNR/DNI, do not hospitalize • Competent patients may request, or may be based on pts advance directive or after talking to surrogate

10. Advance Directives • What are some potential benefits to patients for discussing advance care planning and advance directives? • What are some potential reasons patients may not complete advance directives?

11. Advance DirectivesReasons for not completing • Apathy • Procrastination • Task not perceived as urgent • More highly valued with urgent medical need • Discomfort with the topic • Uncertainty on how to express preferences • Fear of irrevocability • Belief that family will/should decide Miles, SH et al. Arch Intern Med. 1996;156:1062-1068

12. Advance DirectivesChallenges • Difficult to precisely formulate preference • People hedge treatment preferences • Many (30-65%) would rather trust a proxy than express a preference Miles, SH et al. Arch Intern Med. 1996;156:1062-1068

13. Do Proxies know pt preference? • Most people had spoken with preferred proxy about values, but few discussed specific treatments • Formal Ads • either living wills or POA • increase chance a person will detail preferences to proxy • Familial proxies’ estimates of a pt’s preference did not greatly differ from chance • Studies vary on direction of proxy bias compared with agent’s preference Miles, SH et al. Arch Int Med. 1996;156:1062-1068

14. Discussing Advance Care Planning • Discussions often occur over more than one encounter • Goals may vary based on clinical situation

15. Preference • Values • what is important in life and makes life worth living • Goals of medical care • Underlying reasons for treatment wishes or beliefs • Outcomes • Likelihood of return to present state, survival with disability or death • Risk • Some people are risk takers and some are not

16. Initiating the Discussion • Setting • Private and comfortable • No interruptions • Determine who else the pt would like present • Time: “experts” averaged 14.7 min for AD discussions • Decide upon goals for the discussion Roter, DL et al. Arch Intern Med. 2000;160:3477-3485

17. Initiating the DiscussionHow to Start? • Develop supportive relationship • Empathy, concern, praise • Consider obtaining permission to discuss • Orientation • Rationale for discussion • Describe advance directives • Ask whether existing advance directives • ? what the pt already knows and what they want to know Back, A et al. Medical Oncology Communication Skills Training Learning Module 4. 2002 (http://depts.washington.edu/oncotalk/modules.html)

18. Explore patients values and goals • Impossible to elicit preferences for every possible intervention, situation • Focus on values, beliefs and goals • Focus on a few likely issues • Ask about experiences • Personal, family, friends • Explore reasons • Ask why • Shared understanding • “How do you define . . .” Back, A et al. Medical Oncology Communication Skills Training Learning Module 4. 2002 (http://depts.washington.edu/oncotalk/modules.html)

19. Provide Information • Discuss likely Scenarios/Interventions • Be clear and direct; clarify vague language • Outcomes • Discuss Risks/probabilities • Reversibility • Uncertainty • Framing Back, A et al. Medical Oncology Communication Skills Training Learning Module 4. 2002 (http://depts.washington.edu/oncotalk/modules.html)

20. Outcomes • Pts may overestimate likelihood of survival after CPR • Study of 287 ambulatory pts >60yo • Providing probability of survival to hospital D/C after cardiac arrest • Reduced % of pts wanting CPR (41 to 22%) • Percentage of pts desiring CPR lower than in other studies Murphy, DF et al. NEJM,1994;330:545-549

21. Outcomes of In-hospital ArrestSurvival to Hospital Discharge *National Registry Cardiopulmonary Resuscitation Adult and Pediatric: 14,720 cardiac arrests 1/00-6/02 1. Perbody MA et al. Resuscitation. 2003;58:297-308 2. Dumot JA et al. Arch Intern Med, 2001;161:1751-1757 3. Brindley PG et al. CMAJ. 2002; 167:343-348

22. Comments?

23. Surrogate Decision Maker • Refocus discussion toward relationships • “how can you guide your loved ones to make the best decision” vs. “what would you want” • Advise patients to discuss values and preferences with surrogate • Ask how much leeway surrogate should have when interpreting advance directive • Surrogate must be willing/able Prendergast TJ. Crit Care Med 2001;29:N34-N39.

24. Documentation • Formal • Durable power of attorney documents • Living Will document • Informal • Document discussions • Add valuable information about pt’s reasons and values • Document decision-making capacity

25. Final Points • Advance Directives take effect in decisional incapacity • Formal Advance Directives (e.g. living wills) • Part of Advance Care Planning • May be inadequate • To obtain preferences, discussions should address • Pt values and goals • Pts should discuss values & preferences with surrogates • Advance care planning is a process • Readdressed over time

26. Any Questions?

27. References • Back, A et al. Medical Oncology Communication Skills Training Learning Module 4. 2002 (http://depts.washington.edu/oncotalk/modules.html) • Balaban, RB. JGIM. 2000;15:195-200 • Brindley, PG et al. CMAJ. 2002;167:343-348 • Curtis, JR et al. Crit Care Med. 2001;29:N26-N33. • Diem, SJ et al. NEJM. 1996;334:1578-1582 • Dumot, JA et al. Arch Intern Med. 2001;161:1751-1758 • Fischer, GS et al. Clinics in Geriatric Medicine. 2000;16: 239-254 • Hamel, MB et al. JAGS. 2000;48:S176-S182 • Miles, SH et al. Arch Intern Med. 1996;156:1062-1068 • Murphy, DF et al. NEJM. 1994;330:545-549 • Pearlman, RA et al. Patient Education and Counseling. 1995:26:353-361 • Perbody MA et al. Resuscitation 2003;58:297-308 • Prendergast TJ. Crit Care Med 2001;29:N34-N39 • Roter, DL et al. Arch Intern Med. 2000;160:3477-3485 • Teno, J et al. JAGS. 1997;45:500-507 • Tulsky, JA et al. Ann Intern Med. 1998;129:441-449 • www.eperc.mcw.edu